Medicare Advantage Plans
We are specialists of these plans!
What is Medicare Advantage Insurance?
These policies are evolved by insurance carriers typically as wrap around the Original Medicare insurance and contracted with Centers for Medicare and Medicaid Services on annual basis. Insurance carriers generally add additional benefits over and above Original Medicare to make the policy wholesome and easy for you, and ideally include Prescription Drugs coverage making it a one-stop shop. Insurance carriers sell and service these policies under control and standards set by Centers for Medicare and Medicaid Services. The insurance carriers have the power and advantage of creating networks of service areas of different plans, providers, hospitals, pharmacies, and integration with similar out-of-area networks in 50 states. The coordinated healthcare by networks of providers generates higher volume of business and drives down healthcare cost for you. Not everyone can be happy, but the goals and objectives are noble. When you want to sign up for a Medicare Advantage plan with Prescription Drugs Plan, you must be enrolled in Part A, Part B and Part D with the Medicare.
Things to know before I sign up for it
Things to know before I sign up for it?
Medicare pays premiums on your behalf to the insurance carrier. In addition, you may have to pay additional premium to the insurance carrier you sign up with depending upon the plan you wish to buy. Typically, a Medicare Advantage Plan with Prescription Drugs Plan has following coverage of financial risks:
- The policies have full coverage of defined Medicare Part A, Part B, and Part D.
- Each plan has its defined cost sharing of deductible, copayment, coinsurance, maximum ‘Out-of-Pocket’ expense on annual basis [typically $6,700], and the insurer’s service area where it is available. This combination varies over large spectrum of choices by insurance carriers, and so do the insurance premiums for large variety of plans and their availability in area where you live.
- The Part D coverage is defined for deductible and coinsurance. The levels of expense have its own account depending upon the plan.
- There are ‘add-on’ benefits like basic dental and vision and sometimes-free membership of fitness clubs and gyms to encourage you to stay healthy.
- The preventive services are free.
- Sharing for drugs’ coverage that is built into the plan generally works similar to cost sharing in stand-alone Medicare Part D plans.
- You cannot combine stand-alone prescription drugs plan with coordinated care Medicare Advantage plan. You can however combine stand-alone prescription drugs plan with a Private Fee for Service [PFFS] or a Medical Savings Account [MSA] plan mentioned below.
What are different flavors of Medicare Advantage Plans?
All Medicare Advantage plans encourage you to visit the healthcare providers to get services you need to stay healthy. The design of a coordinated care insurance plan derives its name designation from the functional structure of the healthcare providers who accept the insurance health plan structure and contract with the insurance company. The types of plans are listed below:
- Health Maintenance Organization (HMO) plans: In most HMOs, you can only go to doctors, other care providers, or hospitals in the plan’s network, except in an urgent or emergency situation. You may also need referral from your primary care physician to see other doctors or specialist.
- HMO Point of Service plans [HMO POS]: This is modification of basic HMO plan that allows limited ‘out-of-network’ care for higher copayment insurance.
- Preferred Provider Organization (PPO) plans: In a PPO, you pay less if you use doctors, hospitals, and other healthcare providers that belong to the plan’s network. You can go ‘out-of-network’ and pay a little more for the services.
- Private Fee-for-Service (PFFS): PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, and hospital as long as they accept the plan’s payment terms (including your obligation), and above all, accept to treat you except for emergencies. You may buy stand-alone Part D prescription drugs plan if PFFS plan does not include it.
- Special Needs Plans (SNPs): These plans are of special types that are designed for people with special needs who need considerable and well-coordinated medical care. Special Needs Plans serve following groups:
- People who are institutionalized in nursing homes or other long-term care facility.
- People who are eligible for both Medicare and the Medicaid assistance program [dual eligible].
- People with certain chronic diseases, such as heart disease, or diabetes, etc.
- If you are eligible and qualified for such plan, you can join any time of the year.
- Medical Savings Account (MSA) Plans: Medicare MSA Plans are Medicare Advantage Plans [Medicare Part C]. These plans are sponsored by private companies and contracted with Medicare [CMS]. An MSA plan comprise of two parts: 1) It is High-Deductible Medicare Advantage Health Plan; 2) It has Medical Savings Account, which is a special type of savings account that you maintain in the selected bank of your choice, and you report its usage to the IRS with your annual personal tax return. Some features of an MSA plan are as follows:
- The Medicare MSA Plan [issuer of policy] deposits some money in your account for your healthcare costs.
- You may use money out of this account for your healthcare costs, including costs that are not covered by Medicare.
- When you use this money to pay for your healthcare costs during the year, it counts towards plan’s deductible for the year.
- If money in this account is exhausted, you pick up costs until you meet the deductible for the year.
- During the time you pay for your ‘out-of-pocket’ for services before deductible is met, you will only pay Medicare-approved charges.
- Money left in account at the end of the year stays in the account, and may be used for future years.
- The money in this account is not subject to taxes.
- MSA Plans do not cover Part D prescription drugs.
- To check on disqualifying eligibility restrictions on such plan before you consider shopping for this plan, call 1-800-MEDICARE (1-800-633-4227). Check if such plan is available at all in the area of your interest.
I am in low income. Do I get some more help?
Medicare – Medicaid Plans: Medicaid is state sponsored health insurance program for low-income people. It has different levels of Medicaid assistance related to your income level. The centralized administration of state Medicaid programs is coordinated by Department of HHS / Centers for Medicare and Medicaid Services [CMS https://www.cms.gov ].
When you are eligible for Medicaid and you become eligible for Medicare, you become dual eligible. Some Medicare Advantage plans can combine Medicare and Medicaid benefits, so you deal with one set of claims with one carrier.
When can I sign up for Medicare Advantage Plan?
To regulate traffic for new entrants to Medicare and renewal candidates, Centers for Medicare and Medicaid Services have set in stone rules of the road for both types of candidates that all contracted insurance carriers have to abide by, and so do these candidates as well. They are :
When you are new candidate to Medicare
When you are about 3 -4 months short of your birth month, you will get a much awaited ‘red-and-blue’ card from Social Security Administration. Check that start date of Part A and Part B is there on it. If not, call Social Security or Medicare.gov and sign up for Part B and Part D. You need all three components of Medicare insurance, viz. Part A, B, and D.
About 3 months before your birth month, you can shop for buying a Medicare Advantage plan. If you have done your homework well, your Plan begins on the first of your birth month. It is time for celebration. Even if you have missed or delays by as much as 3 months, after your birth month, you are still entitled to enroll in Medicare Advantage plan. Your insurance begins on the first of following month. If you have missed even this, wait for ‘Open Enrollment’ season to begin, as it does for renewal candidates.
When you are a candidate for renewal of Plan
Mark your calendar to change your carrier for the Medicare Advantage plan. These dates are for Annual Enrollment and for making changes. These dates are:
- October 15 – December 7: This is open season for switching from one type of plan to another without you having to give any reason to make changes to your current plan. Changes with take effect on January 1st.
- January 1 – February 14: This is the disenrollment period from Medicare Advantage plan to revert only to Original Medicare plan. You can add Medicare Prescription Drugs Plan coverage to Original Medicare plan. This will take effect on first of the following month. What you cannot do is…
- Switch from Original Medicare to a Medicare Advantage
- Switch from one Medicare Advantage to another Medicare Advantage
- Switch from one Prescription Drugs Plan to another
- Join, switch, or drop a Medicare Medical Savings Account Plan
What if you run into Special Events?
When there are circumstances and events in your life that compel you to make changes to your Medicare health coverage, Medicare accommodates you to initiate and make changes to your existing Medicare health plans. In parlance of Medicare, such ‘Qualifying Events’ trigger Special Enrollment Period [SEP]. It is best to call Medicare at 1-800-633-4227 and find out if you can have this Special Enrollment Period [SEP] approval to make changes. Make note of the reference number that you get and its applicability timeframe within which you can initiate changes in your health coverage plan. Such qualifying events are categorized as follows: Read on…
- Changes in where you live: If you have moved out of service are of your current plan; moved back to the U.S. from living abroad; moved to or moved out of an institution like nursing facility, etc.
- Losing current coverage: This could be due to a number of reasons like you lost your Medicaid coverage, you are not eligible for Extra Help any more, you left coverage from your employer or union, you lost your drugs coverage that was as good as Medicare standards, etc.
- Changes in Your Current Plan: If either the carrier pulls out plan from its service area, or the plan terminates with Medicare, you may initiate for new enrollment option with Medicare by calling 1-800-633-4227.
- Changes Due to Special Situations: There may be circumstances that compel you to make changes to your Medicare health plan. Some typical changes in your situation can be:
- You become eligible for both Medicare and Medicaid.
- You qualify for Extra Help paying for Medicare prescription drugs coverage.
- You are enrolled in State Pharmaceutical Assistance Program [SPAP] and you lose this eligibility.
- You have severe or disabling medically chronic condition that and there is a Medicare Chronic Care Special Needs Plan (SNP) available that will serve you better.
- If there has been an error in your enrollment to the plan.
Tell me about Prescription Drugs Plan in Medicare
Part D of Medicare Insurance helps pay for prescription drugs for your health care. Prescription drugs coverage is an insurance policy you buy from private insurance companies. You can buy a standalone separate policy just for drugs, called prescription drugs plan. Alternatively, you can buy Medicare Advantage plan that includes drugs coverage. Medicare has issued guidelines for the type of drugs that must be covered by drug plans and the minimum standards of benefits. Insurance companies design different plans, which conform to or exceed minimum standards set by Part D. These plans vary by cost, and by their formulary, or list of specific drugs covered.
Drug plans have preferred and non-preferred pharmacies to choose from, and the geographical area they are offered. Medicare Advantage plans with prescription drugs coverage have network of pharmacies that go with the plan and set their own pricing structure. Note that within the same network pharmacy, prices will vary. So, shop for the pharmacy store you will hang your hat on for list of medication you are sure to take. As for non-network pharmacies, the retail prices will typically be more; however, you may find discounted prices.
Cost sharing of prescription drugs is designed based on deductible, copayment, coinsurance, and coverage gap, also called ‘donut hole’, when cumulative total of purchase expenses rise about certain levels. Typically, the annual cost share expenses work out as follows for you in a typical Medicare Advantage Plan, which includes prescription drugs coverage:
- Deductible: This is what you pay upfront for medications at retail price at the pharmacy before cost share with your Plan kicks in. It depends upon the Plan you purchase. Typically, deductible varies from $250 to $415. Assume deductible of $415 for illustration purpose.
- Initial Coverage Limit: (called Donut Hole) After deductible is met, your plan pitches in 75% and you pay 25% of the cost of medicines till the total retail cost of medications you purchase reaches $3,820.Your initial Out-of-Pocket expense: is $415 + 25% of ($3,820 – $415) = $1,266.25.
- Out-of-Pocket Threshold: When you go past this expense of $1,266.25, you pay 100% of the costs of medication until your Out-of-Pocket expense reaches $5,100. This is painful on pocket besides medicines you have to take. Some drug companies do come to rescue to discount the cost of medications for you, so that you keep buying their brand of medication.
- Catastrophic Coverage: Above ‘Out-of-Pocket’ expenditure of $5,100, you enter into what is euphemistically called as ‘catastrophic coverage’ slot, in which the plan pays 95% of costs, and the enrollee pays 5%.
Note that for a heavy user of prescription drugs, this is substantial expenditure. It is important that the enrollee shops for enhanced prescription drugs a plan, which not only has all the drugs that enrollee takes, but it also gives the projected annual expenditure. Click here for more comprehensive review of this topic,
How do I compare Medicare Advantage Plan with Medicare Supplement Plan?
These are two altogether different species, the former is like a wrap around the Original Medicare run and managed by private insurance companies in contract with Centers of Medicare and Medicaid Service, and the latter underlies the Original Medicare insurance as supplement to pick up uncovered portions of Original Medicare. Click here for more details on Medicare Supplement Plan.
Any authoritative publication for me to understand?
Centers of Medicare and Medicaid services publishes annual manual of “Medicare & You”. This booklet reaches in print to new entrants to Medicare Insurance. However, it is downloadable from Medicare.gov site. This is handy for you here: Read more…
Click here to browse at the booklet published by Centers for Medicare and Medicare Service, or
Reading of this booklet is intensive. We have extracted certain pages from 2017 publication and superimposed with explanatory notes and audio to these notes. If this could be of some help, please click here to browse, read side notes, and listen to audio.
Which insurance carrier do you represent?
We represent Unitedhealthcare branded by AARP to vouch for its Medicare Advantage, Medicare Supplement, and Prescription Drugs plans. You are familiar on TV commercials and the mailers in your mailbox when you are close to 65 with this name. When you have enrolled in one of the plans, newsletters and offers, and reminders to take care of your health consistently update you.
Well, what are these plans like and how do I shop?
The power of a Medicare Advantage Plans lies in its support system of the network of physicians, hospitals, services like diagnostics, labs, medical devices, ambulances, pharmacies and ancillary services. With all these medical services and facilities, the carrier enters into contracts, brings down its contract rates for services with them, and places these contract services at the disposal of its member customers, the enrollees with the carrier. Unitedheathcare has a variety of Plans, which are based on the Zip Code for their flavors and prices. Your copays, coinsurance, your maximum out-of-pocket cost are well defined in the set of documents that you get when you enroll. We are placing below Summary of benefits of a set of sample plans available in a selected Zip Code in Florida. To shop for a Plan in the Zip Code you reside in, get know its features it offers through these published documents. This gives you fair idea of what is in it. Browse over these sample Plans and their comparison as follows:
|AARP MedicareComplete (HMO): H1045-030||AARP MedicareComplete Choice (PPO): H2406-010||AARP MedicareCompete Choice Essential (Regional PPO): R7444-004||AARP MedicareComplete Choice Plan 2 (Regional PPO): R7444-003||Summary Comparison of these Plans|
Make it easier! How do I get started?
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